Foreword
This handbook discusses common clinical uses of albumin and not all brands of albumin approved by the FDA are labeled for all these indications
References
1 Smith L . Choosing between colloids and crystalloids for IV infusion . Nursing Times [ online ] 2017 ; 113:12:20 – 3 .
2 Astapenko D et al . Clinical physiology aspects of chloremia in fluid therapy : a systematic review . Periop Med 2020 ; 9 ( 1 ): 40 .
3 Hartog CS , Kohl M , Reinhart K . A systematic review of thirdgeneration hydroxyethyl starch ( HES 130 / 0.4 ) in resuscitation : safety not adequately addressed . Anesth Analg 2011 ; 112 ( 3 ): 635 – 45 .
4 Martin GS , Bassett P . Crystalloids vs colloids for fluid resuscitation in the intensive care unit : a systemic review and meta-analysis . J Crit Care 2019 ; 50:144 – 54 .
5 Evans L et al . Surviving Sepsis Campaign : International Guidelines for Management of Sepsis and Septic Shock 2021 . Crit Care Med 2021:49 : e1063 – e1143 .
6 EASL clinical practice guidelines for the management of patients with decompensated cirrhosis . J Hepatol 2018 ; 68:406 – 60 .
7 Caraceni P et al . Longterm albumin administration in decompensated cirrhosis ( ANSWER ): an open-label randomised trial . Lancet 2018 ; 391 ( 10138 ): 2417 – 29 .
8 China L et al . A randomised trial of albumin infusions in hospitalised patients with cirrhosis . N Engl J Med 2021 ; 384 ( 9 ): 808-17 .
9 Groeneveld JAB . Albumin and artificial colloids in fluid management : where does the clinical evidence of their utility stand ? Crit Care 2000:4 ( Suppl 2 ): S16 – S20 .
10 Aldecoa C et al . Role of albumin in the preservation of endothelial glycocalyx integrity and the microcirculation : a review . Ann Intensive Care 2020 ; 10:85 .
11 Albumin ( Human ) 5 % Solution . ALBURX 5 . Prescribing information .
12 Albumin ( Human ) 25 % Solution . ALBURX 25 . Prescribing information .
Intravenous ( IV ) fluid and volume replacement therapy are two most common interventions within a hospital setting . The goal of fluid replacement is to compensate for imminent or existing fluid deficit within the extracellular space , whereas volume replacement is used to replenish the intravascular volume when large volumes of blood are lost , for example , during traumatic injury .
Adequate fluid replacement can be achieved through the use of either a crystalloid solution or colloid solutions . 1 Crystalloids consist of plasma isotonic solutions containing low molecular weight salts or sugars , that can easily pass between the intravascular and interstitial compartments . Furthermore , crystalloids are available in several different formulations , are relatively low cost , and are compatible with a number of different drugs . Nevertheless , there are some recognised limitations with the use of crystalloids including a potential risk of excess extravascular fluids in peripheral tissues and lungs , which might result in edema and respiratory failure respectively . Another problem with prolonged administration of crystalloids is the risk of hyperchloremic acidosis , which has a negative effect on renal function . 2
The alternative replacement fluid are colloids , which can be either natural , such as albumin , or synthetic , i . e ., hydroxyethyl starch ( HES ) and gelatin . While there is an ongoing debate over the merits of both crystalloids and colloids , one emergent fact over the last few years , has been the potential risks associated with the use of HES . In a systematic review of 56 randomized trials using HES in acute hypovolemia mainly resulting from elective surgery ( n = 45 ), there was no evidence that HES is safe in surgical , emergency or intensive care patients . 3 While the use of HES products is permitted in the US , the FDA continues to warn of the increased risk of mortality and need for renal replacement therapy in critically ill adult patients , including those with sepsis when treated with HES .
Albumin is the main plasma protein , and serves to maintain the plasma oncotic pressure . In a meta-analysis evaluating hemodynamic response to crystalloid / colloids in critically ill adults , crystalloids were shown to be less effective than colloids at stabilizing resuscitation endpoints . Compared with the albumin group , cardiac index was significantly lower in the crystalloid group ( p < 0.001 ). The authors concluded that albumin may be a more appropriate choice of fluid to restore hemodynamic endpoints . 4 In addition , the US Society of Critical Care Medicine has endorsed the
Surviving Sepsis Campaign recommendation that for adults with sepsis or septic shock , albumin should be used in those who received large volumes of crystalloids . 5
Albumin has an important role in patients with cirrhosis and is recommended by the European Association for the Study of the Liver to be used during treatment of spontaneous bacterial peritonitis , acute kidney injury and hepatorenal syndrome , and during large volume paracentesis to reduce the risk of paracentesis-induced circulatory dysfunction . 6 Whether long-term albumin administration in decompensated cirrhosis would have any role remains controversial . The results of the ANSWER trial ( a multi-centered , randomized , open label trial in 33 hospitals ; n = 431 ) showed a clear survival benefit using long-term albumin supplementation in patients with decompensated cirrhosis . 7 However , a large , multicenter , randomized controlled open label trial ( ATTIRE ; n = 777 ) did not show any benefit from this approach in patients with cirrhosis and serum albumin level 30g / l or more compared with standard care . 8
Currently , albumin is approved by the FDA for several indications including hypovolemia ; for prevention of central volume depletion after paracentesis due to cirrhotic ascites ; acute respiratory distress syndrome ; and acute nephrosis . Albumin can also be used in cardiopulmonary bypass procedures .
While albumin has several approved uses , it is increasingly recognised that the protein has additional benefits over synthetic colloids . 9 For example , albumin is the main plasma antioxidant . A further function of albumin is the preservation of the glycocalyx , which together with the endothelium , is damaged in several clinical situations including sepsis , hemorrhagic shock , hypervolemia and hyperglycemia . 10 In fact , this glycocalyx-preserving property has the potential to improve outcomes in many of the clinical scenarios that are characterized by a damaged glycocalyx . 10 Although many physiological and biological functions of albumin make it a very useful drug ,
11 , 12 physicians should use it judiciously .
This educational handbook is designed to provide current information on the use of albumin in different clinical settings . While the physician with overall clinical responsibility for a patient will select the most appropriate fluid therapy , the purpose of this guide is to help support healthcare professionals in their decision-making process , to ensure the delivery of the best possible outcomes for patients , in situations that require the use of fluid and volume replacement therapy .
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